Provider Demographics
NPI:1558025700
Name:IHLY, MELISSA ROSE
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:ROSE
Last Name:IHLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1922 THE ALAMEDA STE 316
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95126-1461
Mailing Address - Country:US
Mailing Address - Phone:408-261-7777
Mailing Address - Fax:408-642-6052
Practice Address - Street 1:86 S 14TH ST
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95112-2015
Practice Address - Country:US
Practice Address - Phone:408-510-7080
Practice Address - Fax:408-510-7081
Is Sole Proprietor?:No
Enumeration Date:2021-10-25
Last Update Date:2023-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician